NHS (Essex)

Priti Patel Excerpts

Tuesday 15th March 2011 Westminster Hall

[Priti Patel (Witham) (Con)]

I am grateful to Mr Speaker for granting me the opportunity in Westminster Hall to draw directly to the Minister’s attention a number of important issues regarding the performance of NHS services in my constituency and in the county of Essex. I suspect that the matters that I shall raise and the constituents’ cases that I shall mention are by no means unique to my constituency or the county. However, the Government are developing the most important and, in my opinion, long-overdue changes to the NHS, and I want to ensure that the problems and challenges faced by my constituents are thoroughly and fully considered.

Throughout the endless reforms and reorganisations undertaken by the previous Government, the health needs of patients were never afforded the same priority as the expanding tick-box bureaucracy suffered by my constituents. One consequence of the waste that was created is that the money put into the health service never achieved the true outcomes that my constituents deserved and needed. That has led in part to my constituents suffering poor patient choice and health care services. However, we cannot change everything about the past.

The Minister, the Government and, most importantly, my constituents want an effective NHS for the British people; it should deliver value for the taxpayer, ensuring that the mistakes of the past are not repeated and that all receive the care and front-line services that are their due. It is therefore essential that as the NHS is reformed, the needs of local communities in my constituency of Witham are not overlooked or ignored. That is why this debate is so timely.

By way of background, I shall give the Minister some details about my constituency and some of the health care challenges faced by my local community and me that are specific to the area, and the nature of current NHS services there. I shall then highlight the excessive and overblown bureaucracy that affects the NHS globally, which demonstrates the scale of taxpayers’ money that is increasingly and wrongly being taken from front-line services. I shall also draw attention to some of the most serious and heart-breaking cases that I have come across in the 10 months since I was elected, which show that the NHS too often fails the most vulnerable. I shall conclude my remarks by putting the case for new NHS services being delivered locally under the Government’s planned reforms.

Witham is a new constituency, so I forgive Members for not knowing much about it. It is not far from the London commuter belt, and lies within the heart of Essex. We have tremendous public transport and road links to London. The ports of Felixstowe, Harwich and Tilbury are not far away, and we have some major industrial towns and centres. It is not surprising, therefore, that Witham has experienced significant population growth in recent years. It is an attractive area to live in.

The three local authority areas in my constituency are Braintree, Colchester and Maldon. Under the previous Government, they were required to build more than 27,000 new homes in the 20 years to 2021, and 60,000 new homes between 2011 and 2031. Throughout Essex, the current population of 1.4 million could easily grow by 14% over the next 20 years. Members will be aware from their own areas that population growth inevitably puts more burdens not only on infrastructure but on the local NHS.

The local plans, particularly those that affect my constituency, unfortunately give no serious consideration to ensuring that the quality and quantity of local health services can keep pace with projected population increases and changing demographics. Although top-down targets are being scrapped by the present Government, the attractiveness and desirability of my constituency inevitably means that more people will move to the area, so we can expect to see a significant increase in the local population. That will put demands on local health services that are already struggling to cope.

It is not simply the sheer quantity of people that NHS services will need to support; they will also need to adapt to the changing demographics of the area. Because our local communities attract young families, we need stronger maternity services and paediatric provision. However, the most significant demographic change will be an acceleration of the number and proportion of residents over the age of 65. In that respect, my constituency and the county of Essex are not unique, as health services across the country are responding to an ageing population. By 2021, the NHS in Essex, along with its partners in local government, will need to accommodate the health needs of 45% more people in the county living beyond the age of 65, and 75% more people living beyond the age of 85.

Some of the most significant increases in Essex are expected to be in the Maldon district, part of which falls within the Witham constituency. It is worth noting that about 10% of the Essex population provides assistance, caring for family, friends or neighbours, with higher than average rates in Maldon, where the number of working-age people available to care for older persons will have nearly halved by 2029. These demographic changes present serious challenges to the front line of the NHS in my constituency and in the county.

I am pleased to report that Essex county council is taking a strong lead in implementing the Government’s reforms to deal with the challenge. It has already established a health and well-being board, and the Department of Health recognises it as an early implementer. I would welcome the Minister’s reassurance that the Government, unlike the Labour party, which has made no commitment to NHS funding to support this work, will continue to increase resources when necessary to support the health needs of my constituency and Essex. I shall emphasise throughout the debate the need for the money to be spent on front-line care, not bureaucracy.

That brings me to NHS bureaucracy in Essex and my constituency, and specifically to our local primary care trusts. The Minister will be aware that the medical needs of my constituents are served by a number of NHS trusts and by the East of England strategic health authority. There is no general hospital in my constituency; local residents usually use the Broomfield hospital run by the Mid Essex Hospital Services NHS Trust, which is based in the neighbouring constituency—that of the Minister of State, Department of Health, my right hon. Friend the Member for Chelmsford (Mr Burns)—or the foundation trust hospital in Colchester for acute care services. Mental health services are provided by the North Essex Partnership NHS Foundation Trust.

My constituents are served by two of the five primary care trusts in Essex. Those who live in the Braintree district council or Maldon district council parts of my constituency fall within the area covered by the Mid Essex NHS trust, whose budget for 2011-12 has increased to just under £520 million. Those who live in the wards covered by Colchester borough council find themselves being dealt with by NHS North East Essex, whose budget for 2011-12 has risen to just under £547 million.

Later, I will give examples of cases in which constituents have faced unacceptable problems with those health trusts. In the meantime, it is worth looking at the obscene levels of bureaucracy, administration and management that have taken hold of those organisations. The number of managers and senior managers employed by the East of England strategic health authority doubled under the previous Government from 1,300 in 1997 to more than 2,700 in 2009. At Mid Essex Hospital Services NHS Trust, more than £10 million is spent annually on 29 senior managers and 79 managers. In the North East Essex PCT and its three predecessor trusts, the proportion of administrative staff rose from 19% to 33% between 2001 and 2009. The number of managers and senior managers increased from 25 to 84.

Finally, Mid Essex PCT, which serves the majority of my constituents, and its four predecessor trusts, saw administration and staffing levels rise from 17% to 33%, and the number of managers go up from 10 to 102. When we consider that those two PCTs were formed from seven predecessor organisations, it is fair to say that the growth in management and administration over eight years is quite shocking. The PCT now spends almost £13 million on management costs alone. That money, which my constituents and I view as hard-pressed taxpayers’ money, has been taken away from essential local medical care to staff a bureaucracy. Mid Essex PCT is also experiencing slippage in progress on its quality, innovation and prevention plan and, as a result, could now miss its year-end target by £2.7 million. On 16 November, the minutes of its remuneration committee, which have not been disclosed fully, indicate that performance bonuses were to be paid to the chief executive and its executive directors.

What concerns me is not just the vast sums of money increasingly flowing into the pockets of bureaucrats and managers, but the way in which the PCT is behaving and functioning since it embarked on its reorganisation. It seems to have no real idea as to what it is reorganising into. That is a cause for alarm. I hope the Minister is aware that last autumn, North Essex PCT and Mid Essex PCT decided to form a cluster with West Essex PCT under a new chief executive. The first I heard of that change was when I received a press release last September. In a massive blaze of glory, it was announced that the chief executive of the strategic health authority would form closer working arrangements with the PCT.

[Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)]

The hon. Lady has spoken at some length and with real passion about money being poured into the appointment of bureaucrats and managers. In her mind’s eye, a hospital bureaucrat is a man in a bowler hat with a brief case, but is she aware that many people who are dubbed managers in the health service are actually former senior nurses, such as her colleague, the Minister, who bring much of their clinical background and expertise to bear on their role? Nurses in particular get a little pained when politicians talk about managers and discount the fact that many of them are people with a very solid clinical background.

[Priti Patel]

I recognise that NHS managers have a range of health care backgrounds and bring a number of skills to the table. Of concern to my constituents though is the fact that we are dominated by managers who tend to have administrative rather than clinical backgrounds, and they are making key decisions about patient treatment, and even about medical care and access to drugs. None the less, I thank the hon. Lady for her comments and her valid point.

This brings me to the overall efficiency and effectiveness of the reorganisation. I have been told that reorganisation will lead to a significant step forward in delivering greater efficiency for the people of north Essex. None the less, I constantly have to ask the PCT, “What does this mean? What will this look like? What are the costs of the reorganisation?” I was told last autumn that the PCT could not quantify the cost of reorganisation as the process of reconfiguration had only just started. I have been asking for updates, but as yet, have not received any. Each time I ask anything, I am told that my question cannot be answered “at this time”.

There is far too much uncertainty. I welcome reorganisation, efficiency drives and reductions in management and bureaucracy costs, but there are major implications for front-line services. The language of the PCT is constantly about reorganisation producing greater efficiencies, which I would not dispute, but the PCT still has no detailed plans to show what the greater efficiencies will look like and what the formation of the new cluster will mean for local services.

The merging of back-office functions to save money is to be welcomed and I have no issue with that. In this case, however, I have discovered that there is no forward plan in the form of a route map and details of how things will operate. I have been asking questions for six months, but I have not received any substantial details about the new cluster, the staffing arrangements and what it will all mean for patient choice locally. I have sent written questions to the Secretary of State about the reorganisation but, again, I have not had a response.

Will the Minister examine this reorganisation and ensure that more information is made available to the public so that they have some sense of what kind of decision making is taking place locally within the new cluster and the PCT, and what it will mean to them in terms of access to health care and local services? It appears that many of the decisions have been taken behind closed doors, with very little accountability and transparency. It is in the public interest to know what has transpired within the reorganisation, and what the new arrangements will look like as well as the costs and the benefits.

As the PCT should rightly be beginning its winding-down process prior to its abolition, I would like to hear from the Minister about the redundancy arrangements for senior PCT managers. I am sure that that is a matter that is naturally in their minds right now. In view of the colossal levels of waste caused by PCTs, my constituents will be very disappointed to see PCT chief executives and other senior directors receive golden goodbyes to boost pension pots or huge redundancy pay-outs. In the interests of accountability and transparency, all constituents across the country will be looking, during the NHS reforms, for some encouragement from the Government on that issue.

Before I move on to some individual cases, let me just say that I make no apologies for being critical of NHS bureaucracy. In my limited time as an MP, I have seen endless examples of red tape standing in the way of my constituents getting the best health care that should be available to them. I am overwhelmed by the whole culture of tick-box management that has pervaded my local NHS. It is something with which I have been battling, day in, day out, on behalf of my constituents. It is an alarming state of affairs.

Let me now draw to the Minister’s attention a couple of cases. I have been in touch with the Minister and the Department about the issue of Sativex. There have been two cases in my constituency in which the PCTs have refused to treat patients on the NHS with the drug Sativex despite their doctors’ recommending its use to help with multiple sclerosis. In both cases, the PCTs have been able to afford to pay more to their managers and to spend more on red tape and bureaucracy, but have refused to provide vital medical treatment to my constituents.

First, Mr Shipton from Tollesbury was recommended Sativex by four doctors, to help his condition. Those doctors are medical experts who have been treating him and who are aware of his condition and medical needs. However, last September Mid Essex PCT, acting through officials sitting on its area prescribing committee, thought that it knew best and decided that it would not accept a request for Sativex to be prescribed to Mr Shipton on the NHS. That left him in considerable pain and distress. It then took more than a month for the chief executive of the PCT to respond to my request for copies of minutes of the meeting at which that decision was made. The minutes stated that the PCT declined to prescribe Sativex to Mr Shipton

“due to a lack of evidence of significant long-term benefit. Clinical trials are of very short duration and do not compare with current treatment.”

Despite that, however, Sativex is already licensed—in fact, it was licensed last June—for use to improve symptoms in multiple sclerosis patients with moderate to severe symptoms, clearing the way for the PCT to prescribe it. Indeed, the PCT itself had made 31 previous prescriptions of Sativex in 2009-10.

My constituent, Mr Shipton, ended up sourcing Sativex privately, at the cost of £125 plus VAT per bottle, which is a course of treatment that lasts for only two weeks. Contrary to the conclusions of the area prescribing committee, the drug is having a hugely beneficial effect on Mr Shipton. If the bureaucracy of the PCT had not stood in the way, he could have received that treatment at a much earlier date and he would not have had to endure extreme suffering and pain, as well as what I would describe as an unnecessary bureaucratic process.

I have another constituent, Mr Cross from Tiptree, who has also experienced horrendous problems. In fact, his wife, Mrs Cross, is on the phone to my office on a weekly basis, updating us about the terrible position that her husband is in and the suffering that he is experiencing. He has had horrendous problems receiving a prescription of Sativex, although in this instance the obstacle has been dealing with North Essex PCT. Mr Cross is wheelchair-bound and in terrible pain, experiencing constant spasms. In fact, he has recently been in hospital. Given his condition, any treatment would be a welcome relief for him. There is double suffering for his wife, as it were, because she is now effectively his full-time carer. Once again, getting access to this drug has been terrible. He has had his consultant neurologist battling for him and making his case, and I too have battled for him and made his case. But North Essex PCT, despite issuing 16 prescriptions for Sativex in 2009-10, still refused to prescribe this treatment for Mr Cross and gave him a highly dismissive response.

When I took up Mr Cross’s case from September 2010 onwards, I began a process of constant correspondence with the PCT. All I received were evasive non-responses and the odd reference to Mr Cross’s “medical needs”, which were then just dismissed. I found that totally unacceptable. Mr Cross’s condition has since deteriorated and he has been in hospital again. There needs to be a recognition of the endless stress and strain that this process puts on his own domestic set-up, especially his dear wife who is now his constant carer.

There is a compelling case for action in both of those cases, to press the PCTs to provide this drug. Also, both of my constituents have made the point that they have spent their lives working hard, doing the right thing and contributing to society. They felt that in their hour of need the NHS would be there for them, but now they feel that it has not been there for them. That is unacceptable. Although I appreciate that the Minister cannot intervene in individual cases, I ask her at least to examine these cases if she possibly can.

There are two other cases that I want to touch on briefly. The first is that of my constituent Mrs Emily Wetherilt, and again I would welcome the Minister looking into it. It is another example of a local PCT failing to perform adequately to meet the medical needs of my constituents. Mrs Wetherilt is 96 years old and requires 24-hour care. However, despite her case meeting the published criteria for NHS continuing health care funding, Mid Essex PCT has refused to provide any care whatsoever. So there has been no support for her from the PCT. Mrs Wetherilt’s daughter has taken up this matter directly with the PCT’s panel twice and she has been declined on both occasions. The PCT categorically refuses to look into this matter again, because an appeal had not been lodged within the two-week window that was available to Mrs Wetherilt’s daughter.

Many of us recognise that in cases such as this one, when a constituent’s family is caring for them, the family’s priority is looking after their family member and it is not to follow an appeals process within a two-week window. People become very emotional and providing care takes precedence. That care is the priority. Consequently, the tone and the attitude adopted by the PCT are utterly bureaucratic and deeply unhelpful.

Mrs Wetherilt’s daughter has also offered to work with the PCT to find out whether it is possible for the PCT to part-fund her mother’s care, but that suggestion was dismissed by the PCT without even being addressed. That is another example of the inflexible bureaucracy that fails to put patients’ care and needs first. It is more about the process—ticking boxes and filling in forms—and that is wrong.

I have a final shocking case to highlight. It is one that I have raised previously in the House and it is that of my constituent, 14-year-old Bethanie Thorn. Last October, Bethanie was struck down with a terrible illness and left bed-ridden. She literally went from being a healthy teenager one day to being completely bed-bound two days later. The cause of her symptoms was unknown and she became unable to eat as her condition deteriorated. Nevertheless, she faced lengthy delays to get an MRI scan and the other vital checks that were needed to diagnose her condition.

It was only last November, when I raised this matter on the Floor of the House, that the Secretary of State looked into Bethanie’s case and appointments were made for her to have an MRI scan. People in urgent need of an appointment should not have to rely on the Secretary of State, local newspapers or their constituency MP to raise their case and sort appointments out. It shows how serious this case was that, shortly after her scan and check-up, Bethanie was admitted to hospital and she was only able to return home two months later, at the end of January. Her mother has effectively become her full-time carer and her family have had to battle at every single stage for care, appointments and treatment, which is appalling. I must say that, if Bethanie had received the appointment that she needed straight away, she would probably be in a better state of health today. The Minister will appreciate that this has been terribly distressing for Bethanie and her family.

When the NHS was pressed about this case, the only explanation given for the delays was something described as a “broken pathway”. I have no idea what a “broken pathway” is in NHS management talk, but the case has highlighted just how damaging poor performance and failures in NHS services can be to individuals. This girl’s life has changed beyond all recognition now. This case also demonstrates what can go wrong when there are endless layers of bureaucracy in the NHS; it was unclear throughout whether it was Bethanie’s GP, the PCT or the hospital services who were actually responsible for ensuring that Bethanie received the care that she needed. There was to-ing and fro-ing constantly—there really was.

Like all Conservatives, at the last general election I was absolutely proud to stand on a manifesto commitment to cut the waste and bureaucracy in the NHS, so that we could invest in the front-line services and give more powers to doctors and patients. I want to reiterate that in my short tenure—10 months—as a Member of Parliament, all I have seen are examples of how bureaucracy has got in the way. If nothing else, I will continue to battle to get the services for my constituents, in the face of adversity—that is, in the face of bureaucracy.

I welcome the measures that have been announced by the Government about the reforms and plans for the NHS. The purpose of mentioning these cases now is to highlight the fact that in Essex we have seen more of the non-medical side of the NHS in action locally than we have of the medical side, which shows the need for reform of patients’ treatment.

Finally, I want to draw attention to the fact that there is some hope for my constituents. That is the hope that they have placed in Government legislation to reform the NHS. As the Minister will recall from Health questions last week, Witham town is the most urban part of my constituency and Witham town council and others have put forward a very strong case for there to be more health care specialist services in our town. Although Colchester, Braintree and Chelmsford all have significant health facilities, including general hospitals and community hospitals, there is nothing for the people of Witham in our town, and there is nothing for the people from the surrounding villages. That gives the impression locally that there is a two-tier health system.

I mentioned at the start of my remarks that the Witham area includes some pockets of serious deprivation and has a growing population. Unfortunately, the PCT has not taken enough action to close the gap created by the changing demographics and local needs. Maltings Lane is a new housing development in Witham town. It has evolved over a number of years, and many more new homes and other facilities will be built there over the next 10 years, but it was begun with no plans whatsoever for additional health care services. That issue needs to be addressed in the long run, and I hope that the Minister can help my town council, along with our district and county councils, to work with the PCT and the forthcoming GP consortia to develop additional local services that seek to meet local needs. The issue is one of supply and demand, and there is a crying need but no provision.

As a starting point, the town council, to its credit, is working cross-party locally with all our councillors, and has put together a list of services that Witham needs, including an additional surgery, an out-of-hours walk-in clinic, minor injury, oncology and out-patient clinics and a diversity of medical-testing facilities. By adding some of those services to Witham and the surrounding communities, we will naturally see real benefits in the form of health care provision, choice and diversity, and we will enjoy the convenience of more local NHS services.

I am conscious that I have spoken for a considerable time and that many other Members wish to speak, so I shall conclude by saying that although I could raise many more health-related issues, I hope that I have given the Minister a real insight into the challenges that we face in Mid Essex, where we are surrounded by a lot of health activity but have had this bureaucracy that has stifled both the delivery of front-line care to patients, and the choice aspect of health care provision locally. I thank the Minister and colleagues for their patience in listening to my remarks, and I look forward to the Minister’s response.

--- Later in debate ---

[Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)]

The hon. Member for Witham (Priti Patel) is to be congratulated on obtaining the debate. Many of my constituents move to Essex as a kind of upward trajectory, so I listened with great interest to what she had to say about a part of the world with which I am not as familiar as I probably should be. The week after the Lib Dems have turned savagely against the Conservative-led coalition’s health care policies—the British Medical Association is debating them today and, as we know, doctors are very worried about what is proposed—hon. Members will expect me to touch on the health reforms generally and how they will affect the people of Essex.

I listened with some sympathy to the complaints of the hon. Member for Witham about bureaucracy. As I have been a Member of Parliament for 20 years, I have tangled with more bureaucrats than I care to remember. However, I always like to stop short of sounding as if I am dismissing people who work for the health service as a whole. My mother was a nurse. She was one of that generation of West Indian women who helped to build the health service after the war. We have to remember that however frustrating it is as Members of Parliament or even as members of the community to deal with bureaucrats in the health service or elsewhere, there are thousands and thousands of people without whom the health service could not work or function. They will tell us that they have survived more reorganisations than they care to remember. They are still there, getting their heads down and trying to provide a service for our constituents.

The hon. Member for Witham made an important point about the proportion of elderly people in our population. We do not have time to deal with that matter fully, but people are living longer and they are suffering from ailments such as Alzheimer’s and other things. Elderly people make up an increasing proportion of the population. A few weeks ago, I went to a nursing conference and a senior nurse said to me that, when she was on the wards, the mean age of elderly patients was about 80. The mean age of elderly patients is now 90 or 100. Elderly people now pose very different problems from those that the elderly posed a few years ago. It is important that we consider the question of how we secure high-quality care—I am reminded of that awful ombudsman report that was published a few weeks ago—how we pay for it and how health care interconnects with the issues of public health and social care. I hope that we will have a chance to return to those matters.

I remind the hon. Lady that, despite her letters to bureaucrats and her undoubted frustrations on behalf of her constituents, when my party left office, satisfaction with the health service was the highest it has ever been. Hon. Members can say that the population was deluded on that, but I do not think that that is correct. We are talking about massive MORI polls. People’s satisfaction was higher than ever. There had also been massive levels of investment, not least in Essex. She will be aware of the new unit at Colchester general hospital, which includes an updated children’s ward. It is fully open and operational, and that £20 million project marks the biggest investment in the hospital’s facilities since it opened in 1985.

Apart from general frustration with bureaucracy, there are specific issues in relation to health care in Essex that are worth mentioning in this short debate. The hon. Lady mentioned Broomfield hospital. She will be aware that, just a few weeks ago, it was highlighted that although the hospital takes more than £1 million a year in car parking charges, its car parks still lose money because it is spending £1.2 million on running costs, including on CCTV, attendants and capital investment—they must be extremely well paid attendants. We also know that the hospital’s move into its £148 million PFI wing was delayed twice before finally opening in late 2010. The opening day was pushed back because staff were trapped in faulty lifts. We also know that the same hospital spent £400,000 on art for its new wing, which was commissioned as part of the development and funded through PFI. PFI is expensive enough—we may debate that at another time. To spend the money on art, when we know how ridiculously expensive PFI can be, seems quite strange.

There have been all sorts of care warnings about hospitals in Essex, such as Queen’s hospital in Romford. We know that the Romford project will be the first of a number of pilot reviews of PFI contracts to see if the costs can be brought down, and anyone who cares about the health service must welcome that. We know that the Braintree community hospital has defended itself after paying out nearly £20 million in damages for clinical negligence. If we are focusing on bureaucracy, we have to focus on how those things happen. We know that the Southend University Hospital NHS Foundation Trust, with which hon. Members will be familiar, has had to respond to concerns about safety, which were raised by the Care Quality Commission. We know that the West Essex primary care trust risks not being able to give an 18-week referral-to-treatment time. We know that NHS South West Essex has a very large overspend—its deficit has been improved, but it still has an overspend—in relation not to bureaucrats, but to acute hospital activity.

We also know, which I find alarming, that the Basildon and Thurrock University Hospitals NHS Foundation Trust is now trying to make savings by allowing waiting lists to extend. That implies a 14-week wait on first appointment, which is why an hon. Member on the Government side said that, when ordinary residents and voters are told that money on the health service is being ring-fenced, it rings rather hollow. Up and down the country, not just in Essex, they can see waiting times lengthening, and new hospitals and new health care facilities that have been promised being delayed. It is for the Government, who have made much of their protection of health care spending, to explain that. The real issue is this. The hon. Member for Witham spoke glowingly about the reforms, but sadly I have news for her. She seems to believe that those reforms will help with the issues that she has raised. As she would know, however, if she had followed the Health Committee, there is a real challenge involved in trying to introduce those reforms, whatever we think of them, while at the same trying to achieve unprecedented savings in health care. The Health Committee doubts whether that can be done.

No one argues with the notion that GPs could have a lot to offer in the commissioning of care, but as the president of the Royal College of General Practitioners has said, there are other ways to do that without subjecting the health service to a top-down reorganisation. I do not want to be unpleasant, but the Government promised, all through their time in opposition, that they would not subject the health service to any top-down reorganisations.

[Priti Patel]

Will the hon. Lady give way?

[Ms Abbott]

Time is against me, because I want to give the Minister plenty of time to respond. That is what we were promised—no more top-down reorganisations. As for waste of money, one problem with letting all those PCT bureaucrats go is that they have to be paid redundancy. The hon. Lady said that she hopes that they will not be paid big redundancy packages. I am afraid that they will be, and many will be re-employed. GPs will be less accountable to patients and the danger that many people, including GPs, see is that the big American health maintenance organisations will be able to get inside and act as commissioners for GPs, who, after all, joined the health service to heal and not to be managers.

I feel sorry for Government Back Benchers. They believe that the issues that they find so challenging about bureaucracy, cuts and patient accountability will be solved by the reorganisation. I can say with complete confidence that, if anything, the reorganisation, which is too fast and at the wrong time, will make those problems worse. It gives me no pleasure to say that, but anyone who has analysed the so-called reforms can see that they are a car crash in slow motion.